Individual
DR. JOSEPH JELLICORSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
100 PROFESSIONAL PARK, SUITE 204, CARROLLTON, GA 30117-3874
(770) 834-3351
Mailing address
100 PROFESSIONAL PARK, SUITE 204, CARROLLTON, GA 30117-3874
(770) 834-3351
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
046974
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00823028A
—
GA
01
—
080157122
RAIL ROAD MEDICARE
GA
01
—
728652
BLUE CROSS
GA
Enumeration date
11/02/2005
Last updated
09/19/2012
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